REQUEST FOR EXAMINATION, TREATMENT AND/OR PRESCRIPTION AND/OR DEVICE OR METHOD.
 

DATE ____________ NAME OF PATIENT _____________________________________
 

DATE OF BIRTH _______________ FHC PATIENT ID NUMBER ______________________________
 

I have received from Dickinson College Health Center a fact sheet containing information on the use, effectiveness, and known risks of the available contraceptive drugs including oral contraceptives (birth control pills), diaphragms, and other contraceptive methods. I have read the fact sheet, which has been explained to me and I understand it. I also understand that a doctor/nurse practitioner is available to answer any questions that I may have. No guarantee or assurance has been made to me as to the results which may be obtained if I use any of the methods described in the fact sheet, and I am aware on the basis of the fact sheet and the explanation I received of the possible adverse consequences and side effects of the various methods as set forth in the fact sheet.
 

I hereby request that a person authorized by Dickinson College Health Center examine me and that a suitable contraceptive drug, device, or method be prescribed or fitted. I understand that the clinician reserves the right to refuse the birth control method of my choice, if in the clinician's judgement, there are medical contraindications.
 

I understand that it is my responsibility to inform Dickinson College Health Center of any problems or difficulties that occur while using the prescribed contraceptive method and/or procedure. I also understand that I am responsible for returning for my regularly scheduled visits as instructed.
 

Dickinson College Health Center reserves the right to refuse treatment to anyone if, in the clinician's judgement, the patient is unwilling to abide by the protocol and policy of the Dickinson College Health Center.
 

We receive a government subsidy which helps to pay for your family planning services, however, it does not cover the full cost of your services. We must also charge you a fee for some services and supplies to cover our cost. Please let us know if you have a problem with paying your fee. If you feel you are unable to pay, your records in the Financial Aid Office will be reviewed to substantiate (or verify) your inability to pay. Based on that review no patient unable to pay will be denied services.
 

DATE ___________ SIGNATURE OF PATIENT ___________________________________________

I have witnessed the fact that the patient received, read and said she understood the fact sheet.
 

DATE ___________ SIGNATURE OF WITNESS ___________________________________________
 

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REV. 3/99